Austin C. Bourgeois, Austin R. Faulkner, Yong C. Bradley, Kathleen B. Hudson, R. Eric Heidel and...

Fluoroscopically Guided Lumbar

PunctureAustin C. Bourgeois, Austin R. Faulkner, Yong C. Bradley,

Kathleen B. Hudson, R. Eric Heidel and Alexander S. Pasciak

University of Tennessee Medical Center

Knoxville, TN 37922

Fluoroscopically Guided Lumbar Puncture (FGLP)

Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications

Indications

Investigate/exclude meningitisViral, bacterial, fungal, carcinomatous

Investigate demyelinating diseaseMultiple sclerosis, Guillian Barre

Investigate subarachnoid hemorrhage

Indications

Evaluate intracranial pressurePseudotumor cerebri, intracranial

hypotension Infuse contrast for myelogram Intrathecal therapy

Chemotherapy, antibiotics, baclofen, anesthesia

Remove CSF to treat intracranial hypertension or cryptococcal meningitis

Fluoroscopically Guided Lumbar Puncture (FGLP)

Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications

Contraindications

Regional cellulitis Uncorrected Coagulopathy

Poorly studied, based on best clinical judgment and institutional protocol

INR > 1.5Platelets < 50,000Hold Heparin and low-molecular weight

heparin for at least 1 half-life

Contraindications

Suspect Increased Intracranial Pressure (ICP) Clinical manifestations: papilledema, focal

neurological deficit CT findings of hydrocephalus or intracranial

hypertension Allergy to medication (relative)

Lidocaine and latexContrast if myelogram

Fluoroscopically Guided Lumbar Puncture (FGLP)

Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications

Cerebrospinal fluid (CSF) Dynamics

Opening Pressure60 to 200 mm H2O is normal in patients

greater than 8 years old60 to 250 mm H2O in obese patientIntracranial hypotension diagnosed with

opening pressure less than 60mm H20

Cerebrospinal fluid (CSF) Dynamics

Adults have 125-150 mL of CSF CSF is Produced at 0.3 mL/min 9-10 mL – “Standard” amount removed

Replaced in 30 Minutes

Cerebrospinal fluid (CSF) Collection Common CSF tests

MicrobiologyXanthochromiaCytologyOligoclonal bandsLactateAngiotensin converting enzymeViral PCRCytospin (CNS lymphoma evaluation)

Each of the above require 20 drops of CSF each with the exception of cytology, which requires 50 drops

Fluoroscopically Guided Lumbar Puncture (FGLP)

Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications

Most Common Complication: Spinal Headache Positional headache occurs in approximately

32% patients after LPOnset usually 24-48 hours after LP, can occur up to

12 days Greater than 85% of headaches after LP will

spontaneously resolve Can have clinical symptoms similar to meningitis

Photophobia, nausea, stiff neck Pain worse in the upright position and with

coughing/straining, better when supine

Other complications

Incidence of each of these is quite rareBleeding

○ Epidural hematoma rareInfection

○ Wear a mask and use sterile techniqueHerniation

○ Reported in the setting of normal pre-procedural CT

Arachnoiditis and nerve root injury

Fluoroscopically Guided Lumbar Puncture (FGLP)

Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications

Anatomic Landmarks

Conus medullaris terminates at the L1 level in approximately half of adults

Conus medullaris terminates just below L1 level in a significant minority

Take-home point: Go below L1/2

Frank H. Netter; Netterimages.com; “Lumbar Vertebrae and Intervertebral Disc”. Image #4617. Accessed 12/10/2014. Used with permission

Fluoroscopic Anatomy

Important landmarksPedicleSpinous processesVertebral body corticesFacets

Easy to get disorientated

Frank H. Netter; Netterimages.com; “Lumbar Vertebrae and Intervertebral Disc”. Image #4617. Accessed 12/10/2014. Used with permission

Superior articular facet

Inferior articular facet

Pedicle

Spinal process

Technique

Multiple tissue planes crossed Tactile feedback commonly experienced

at two tissue planesInterspinous ligamentLigamentum flavum

Technique

Frank H. Netter; Netterimages.com; “Lumbar Puncture and Epidural Anesthesia”. Image #8083. Accessed 12/10/2014. Used with permission

Benefits of oblique approach

Improved visualization Larger access window

Avoid spinous process Avoid thick interspinous ligaments

Fluoroscopically Guided Lumbar Puncture (FGLP)

Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications

Prevent Spinal Headache

Larger bore needle increases risk16G to 19G – 70% risk 20G to 22G – 20-40% risk24G to 27G – 5-12% risk

Bevel direction matters: Studies of spinal anesthesia have shown at least 50% decrease in HA when bevel is parallel to dural fibers

Prevent Spinal Headache

Insert stylet when removing needleReduces headache and rare incidences of

meningitis and epidermoid tumor formation

Use atraumatic needlesLevel 1 evidence in anesthesia literature

that atraumatic needles such as Whitacre and Sprotte reduce spinal headache

Prevent Spinal Headache

Atraumaticneedles

Image by Shannon K. Campbell, University of Tennessee Medical Center. Artwork created for this publication.

Prevent Spinal Headache

Amount of spinal fluid removed is NOT as risk factor

No convincing evidence that fluid hydration decreases risk

Data is inconclusive whether recumbency after procedure reduced headache

Treat Spinal Headache

Epidural blood patch 20cc autologous blood administered into

epidural spaceSuccess rate lower if performed within first

24 hours Success rates 70-98% have been reported

Caffeine Small studies showed doses of 500mg

relieved 75% of spinal headaches~ 6 Red Bull drinks

Complications: improper needle placement

Common problemsToo shallow – problematic in larger patientsToo deep – into disk space or vertebral body

in the setting of osteoporosisOff target – osteophytes can be difficult to

resolve fluoroscopically Can always evaluate depth with cross

table lateral radiograph

X

Optimal targeting, but no CSF return

Too shallow needle placement

Optimal placement in the spinal canal

Needle into disk space

Needle into bone (osteoporosis)

Fluoroscopically Guided Lumbar Puncture (FGLP)

Indications Contraindications CSF dynamics Complications Anatomic considerations Avoiding complications

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3. Schievink, W. I. et al. Diagnostic criteria for headache due to spontaneous intracranial hypotension: a perspective. Headache 51, 1442–1444 (2011).

4. Evans, R. W. Complications of lumbar puncture. Neurologic Clinics 16, 83–105 (1998).

5. Ahmed, S. V., Jayawarna, C. & Jude, E. Post lumbar puncture headache: diagnosis and management. Postgraduate Medical Journal 82, 713–716 (2006).

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7. DePhilip, R. M. Atlas of Human Anatomy, by Frank H. Netter and edited by Jennifer K. Brueckner, et al. (2008).

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